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. <br /> Please check one: New� Addition Limited Energy Technology <br /> Systems License# <br /> JOB SITE � Z-t�C� LV+:�u t� �' �� <br /> Owner's Name l� '�.�� Telephone Number�j�� � �����—������ <br /> MailingAddress l�`(� L �., � ";���.�rv�% f���)�V� S �5 j�j �� � <br /> Sprinkler Contractor's Name 5'�. ��-- Telephone Nutnber <br /> > <br /> Contact Person ` �+-� %4 �;c <br /> Mailing Address - - <br /> WATER SUPPLY <br /> Lake Well� City <br /> BACKFLOW DEVICE <br /> AVB PVB� <br /> Year of <br /> Make Model Manufacture uanti <br /> Sprinklers_ � �dvt-� <br /> TOTAL <br /> HYDRAULIC CALCULATIONS Design Data: <br /> Area of Application: Sq. Ft. <br /> Coverage per Sprinkler: Sq. Ft. <br /> No. of Sprinklers: <br /> Total Water Required: GPM <br /> PERMIT FEE CALCULATION <br /> 1. Permit Fee $ 35.00 <br /> 2. State Surchar�e $ .50 <br /> 3. Mail-In Fee $ 1.50 <br /> 4. TOTAL PERMIT FEE (Add lines 1-3 above) $ 3f,',�-�] <br /> The undersigned hereby applies to the City for issuance of a Sprinkler System Permit, agrees to do <br /> all work in strict accordance with the ordinances of the City and State regulations, and certifies that <br /> all statements made on this application are complete, true and correct. <br /> y� �� � <br /> Applicant . (��.0 Date �,— �� "� <br /> *****************�x***********�*��* �************�***�*�**�**********x�*�********* <br /> Approved Approved with Corrections �� <br /> Reviewed By: G�� ' Date � — �� '�� <br /> � CG�\\ � � :�S�Jt L�--�o� .�.,1.0 ,� �bn�le-�Q t� <br />